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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> JVIRONMENTAL HEALTH DIVISK <br /> APPLICATION FOR UNDERGROUND STORAGE TANrCLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOLIt SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AR SIN ICATE PERMIT TYPE: <br /> "I�i2Etu Caw <br /> O REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE It G ODZ'Z PJZOJECT CONTACT /tt PHONE# #07 164 <br /> FACILITY NAME PlesPHONE# AI <br /> ADDRESS <br /> CROSS STREET <br /> OWNER 6PERAFOR Z 1 J PHONE# DVZ,S <br /> S <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# ` O <br /> CONTRACTOR ADDRESS Qp i CA LIC# 2z CLASS <br /> INSURER CGOYZ 1) WORKER COMP# /,3 L/7 — 5 <br /> -640 <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME b 4 d COUNTY .S PHONE# 2 U <br /> SAMPLING FIRM ei PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESE T& PASTn DATE INSTALLED <br /> 39- tl� PyleV <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE TITLE DATE e J6 -q� <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND.00R ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME ( DATE <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST BE U MITTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> Cl) <br /> elf- <br /> ('z Te s + M T 13€ o-� R1-F X BDao off. <br /> EH 23 D46(REVISED 10/19/98) Page 3 <br />